Provider Demographics
NPI:1639222532
Name:MEHREN, ANNETTE (DDS)
Entity Type:Individual
Prefix:MRS
First Name:ANNETTE
Middle Name:
Last Name:MEHREN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 LAWTON RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-2361
Mailing Address - Country:US
Mailing Address - Phone:708-528-1313
Mailing Address - Fax:
Practice Address - Street 1:927 S MANNHEIM RD
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-2565
Practice Address - Country:US
Practice Address - Phone:708-349-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026274122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9176256Medicaid